Effect of routine preoperative fasting on residual gastric volume and acid in patients undergoing myomectomy.

BACKGROUND: Preoperative fasting of patients aims to reduce the residual gastric volume (RGV). The magnitude of this reduction is yet to be ascertained in the Nigerian population. AIM: To compare the RGV and pH of patients fasted for 6-12 h with those allowed oral intake of fluid up to 2 h preoperatively. SUBJECTS AND METHODS: This randomized study involved 90 American Society of Anesthesiologists physical status I-II patients booked for abdominal myomectomy under general anesthesia. The patients were randomized into three groups. Preoperative fasting from midnight (Group F, n = 30) was fasted from midnight to the operation time. Carbohydrate-rich drink group (Group C, n = 30) received 800 mL of oral carbohydrate solution in the evening before surgery (22:00 h). An additional 400 mL was given 2 h before anesthesia. Placebo drink group (Group P, n = 30) received water in the same protocol as Group C. The Student's t-test was used to analyze RGV and pH postoperative satisfaction and postoperative nausea and vomiting (PONV) were compared on a visual analog scale. RESULTS: The RGV and pH were similar for all groups (P = 0.45 and 0.90, respectively). Antiemetic consumption and PONV scores were lower in Group C compared with Groups F and P (P = 0.01). Patients' in Group C had higher satisfaction (P < 0.001). CONCLUSION: Preoperative carbohydrate or water intake up to 2 h before surgery is safe with better satisfaction when compared to overnight fasting.

The efficacy of chewing gum on postoperative ileus following cesarean section in Enugu, South East Nigeria: A randomized controlled clinical trial.

BACKGROUND: Postoperative ileus (POI) is a common complication following caesarean section. It impairs patients comfort; delays wound healing and prolong duration of hospital stay. Several methods have been used in the management of this condition with varying efficacy. Chewing gum postoperatively is a recent concept in the western world being advocated as a cost effective and comfortable management of POI. AIM: The aim was to evaluate the efficacy of gum-chewing in reducing POI following caesarean section in Enugu. MATERIALS AND METHODS: One hundred and eighty women booked for elective caesarean section were randomized into gum-chewing group (n = 90) or control group (n = 90) The subjects chewed sugarless gum three times daily from 6 h postoperatively until the first passage of flatus. Each chewing session lasted 30 min. Elective cesarean section was carried out with a Pfannenstiel incision. Groups were compared primarily for time to first bowel sound, and first flatus. Secondary endpoints of comparison were time of operation to first defecation, and patient satisfaction concerning postoperative gum chewing. The Student's t-test and Pearson Chi-square test and multiple linear regression were used for statistical analysis. RESULTS: The groups were comparable in age, body mass index (BMI) and duration of surgery. The mean time to first bowel sounds (21.9 ± 8.0 vs. 26.1 ± 10.0), mean time to first flatus (24.8 ± 6.4 vs. 30.0 ± 10.0) and mean time to defecation (30.7 ± 5.9 vs. 40.0 ± 9.0) were significantly reduced in patients that chewed gum compared with controls. P =0.02, 0.01, and 0.01, respectively. Patients were satisfied with gum chewing and no side-effect was recorded. Previous surgery and duration of surgery were predictors on duration of POI, while age, BMI and parity had no effect. CONCLUSION: Gum-chewing has a beneficial effect on early return of bowel function following cesarean section and should be included in the postoperative management protocol.

Anaesthetic requirement in spinal cord injured patients undergoing operation below the level of cord injury.

BACKGROUND: Anaesthesia in spinal cord injured (SCI) can be hazardous. In complete injuries above T6, the abnormal state of the respiratory and the cardiovascular systems pose special problems. The objective of this study therefore was to evaluate the anaesthetic requirements in patients with complete SCI undergoing operation below the level of the cord lesion. PATIENTS AND METHOD: The medical records and the operation notes of all patients with complete SCI who underwent surgical operations between January 2001 and December 2005 were reviewed. Information about their demographics, level of injury, indications for operation, type of operation done and the type anaesthesia used were collated. The choice anaesthesia was guarded by the proximity of operation site to the level of cord transaction and by patient's preference. The pre-operative and intra-operative blood pressure, pulse rate and respiratory rate were used to monitor cardiovascular and respiratory responses. RESULTS: They were twenty-eight, all male except one. The age range was 13-67 years with an average of32 years. The level of cord lesion varied. The thoracic spine was most involved followed by the cervical spine. The most common indication for operation was pressure sore. The anesthetic requirement varied, and ranged from general anesthesia (GA) to no anaesthesia at all. Three broad groups were observed: no anaesthesia; sedation with diazepam; and general anaesthesia. There was no remarkable change in the blood pressure readings in the three groups. However, three patients who had GA and whose operation sites were in the twilight zone had remarkable changes in the pulse and respiratory rates. CONCLUSION: Even though spinal patients are insensate below the level of their injury, significant proportions that need operation below the level of cord lesion require anaesthesia.

A survey of blood conservation methods in clinical practice in some urban south-eastern government hospitals in Nigeria.

UNLABELLED: GENERAL OBJECTIVE: To assess the practice of blood conservation. SPECIFIC OBJECTIVES: To determine the methods of blood conservation in use, to assess the lower limit for hemoglobin for elective procedures, to determine transfusion trigger point in practice, to find out limitations in practice and ways to improve clinical practice. MATERIALS AND METHODS: This was conducted in February 2009. Self-administered questionnaires were distributed among the surgeons and anesthetists in practice at the University of Nigeria Teaching Hospital, Enugu State University Teaching Hospital, Ebonyi State University Teaching Hospital and National Orthopaedic Hospital, Enugu. The data gathered was analyzed using the SPSS software. RESULTS: : Of participants who agreed to fill the questionnaires, more than 50% were males. The most prevalent specialty was general surgery (24.2%), followed by orthopedics (22.6%), obstetrics and gynecology (20.7%), and anesthesia (17.7%). The lowest hemoglobin limit before the patient was allowed into the theatre for elective procedures was 10 g/dl while individual transfusion trigger points ranged from hemoglobin of 6 to 10 g/dl. Majority of the doctors would avoid homologous blood transfusion in order to avoid transfusion-related diseases and reaction. Regarding knowledge of blood conservation methods and means of avoiding homologous blood, the use of diathermy was highest (12.33%), followed by preoperative blood donation (11.87%), use of hematinics (10.96%), and tourniquet 10.5%. Also, in practice, diathermy was the most frequently used (18.69%), followed by preoperative blood donation (16.16%), use of tourniquet (15.15%), while the Ovadje cell saver was least with 0.01%. Suggestions from respondents on the ways of limiting transfusion-related problems included optimization of patients (24.5%), improvement of standard of living (17.7%), and personnel training (13.3%). CONCLUSION: There is an agreement with the global trend geared toward minimizing the use of homologous blood by doctors in these hospitals. However, our practice must continually be refined by continuing medical education in order to keep everyone informed of changes in practice. The Government must improve the quality of service by the provision of unavailable infrastructure.

Pre-operative Anaesthesia visit: Problems and Prospects in a University Teaching Hospital in Enugu; South East Nigeria

Background: Pre-anaesthetic evaluation is a basic component of safe anaesthetic practice and ends with the establishment of an anaesthetic plan of action for individual patients. Objectives: The aim of the present study was to assess the difficulties encountered by the anaesthetist during such visits and suggest ways they can be overcome Subjects and Methods: The `activity book' of anaesthetic resident doctors in the hospital was reviewed retrospectively for documented problems they encountered during the pre-operative visit. The problems listed were then subjected to analysis using the SPSS 17. Result: The commonest problem was the unavailability of the patient for review 73.1followed by very busy schedule (7.4) and unfit patients (6.9) Conclusion: Anaesthetists still do encounter problems during the pre-operative visit. Exposing such problems creates the necessary awareness for improvement of patient care

General anesthesia for repair of omphalocele in a pair of conjoined twins in Enugu, Nigeria.

Conjoined twins have been viewed with fascination since antiquity. There are numerous reports in the literature documenting anesthetic management strategies for the separation of conjoined twins. There are also reports in the literature detailing anesthetic approaches for surgical procedures not involving separation. This is the first report of the anesthetic management of a set of omphalagous presenting for palliative repair of omphalocele in Nigeria.

Laparoscopically assisted vaginal hysterectomy in southeast Nigeria--case report.

BACKGROUND: We present the first laparoscopically assisted vaginal hysterectomy (LAVH) performed in our centre and indeed in southeast Nigeria. METHODOLOGY: The case records of a 60 year old post menopausal woman; Para 6(+2) with moderate cystocele, treated at the Nnamdi Azikiwe University Teaching Hospital in July 2007 was retrieved for presentation. RESULT: A 60 year old post menopausal woman, Para 6(+2) with moderate cystocele, no descent of the cervix and narrowed vagina. LAVH and anterior colporraphy was performed. She had an uneventful post operative stay and was discharged home. She has not experienced any complication one year after the procedure. CONCLUSION: LAVH is our first major gynaecological laparoscopy surgery and we consider it an important breakthrough worthy of reporting.

Typhoid ileal perforation: analysis of morbidity and mortality in 89 children.

BACKGROUND: Typhoid ileal perforation is still prevalent in many developing countries. Despite the advances in the management, the outcome in children is still very poor. OBJECTIVE: To determine the morbidity and mortality of childhood typhoid ileal perforation in a tertiary referral centre in southeast Nigeria. METHODS: Retrospective evaluation of 89 children operated for typhoid ileal perforation over a 10-year period (January 1, 1995 through December 31, 2004) at the University of Nigeria Teaching Hospital, Enugu. RESULTS: There were 54 (60.7%) boys and 35 (39.3%) girls aged 1 15 years (mean 9.1 years). Thirty-nine (43.8%) were > 10 years. Fever and generalized abdominal pain were the predominant symptoms for 5 21 days (mean 13.4 days) and 2 13 days (mean 8.8 days) respectively before presentation; Seventeen (89.5%) of those < 5 years had vomiting. Pneumoperitoneum was demonstrated radiologically in 59 (66.3%) children. Surgical treatment involved simple closure in 46 (51.7%) children and segmental intestinal resection in 43 (48.3%). Surgical site infection 41 (46.1%), chest infection 21 (23.6%) and reperforation 19 (21.3%) were the commonest postoperative complications. The overall mortality was 17 (19.1%) from overwhelming infection. Age < 5 years and prolongation of perforation-operation interval worsened morbidity and mortality. CONCLUSION: Typhoid ileal perforation in childhood is associated with high morbidity and mortality. Outcome can be improved by early presentation and intervention.

Pain perception among parturients in Enugu, South-eastern Nigeria.

In order to evaluate pain perception among parturients in Enugu, South-east Nigeria, a cross-sectional questionnaire study of parturients who delivered vaginally in four health institutions in Enugu from 2 December 2005 to 21 January 2006 was administered. Data analysis was by means of percentages, means +/- SD, correlation coefficients, t-tests, chi2-tests, one-way ANOVA and other inferential statistics using the statistical package SPSS for MS Windows at the 95% confidence level. A total of 250 questionnaires were distributed, out of which 181 were correctly filled and returned for a response rate of 72.4%. On a scale of 0 to 10, with 0 representing no pain and 10 representing maximal pain, the mean intensity of pain recorded by the respondents was 7.7 +/- 2.8. A total of 40 (22.1%) parturients received some pain relieving drug during their labour while 141 (77.9%) did not. Of the 40 women who received intra-partum analgesia, three women received pethidine, 17 (42.5%) received pentazocine, while 20 (50%) did not know the analgesic they received. Of the 141 respondents who did not receive intra-partum analgesia, 79 (56.0%) would have liked to have receive analgesia, while 62 (44.0%) would not. Of the 92 women who had their backs rubbed by companions during labour, 67 (72.8%) reported that this practice was helpful in relieving their labour pains, while 25 (27.2%) did not find it helpful. Of the 141 women who had a companion, 103 (73.0%) reported that this was helpful in relieving labour pains, while 38 (27.0%) reported no benefit. Antenatal care, place of residence, ethnicity, religion, marital status, occupational level, receiving intra-partum analgesia, type of analgesia received, having a companion during labour or receiving lectures on labour pains during the antenatal period had no significant impact on pain perception by the respondents (p > 0.05 for each of these variables). There was no significant correlation between pain scores and the respondents' ages and gestational age at delivery (p > 0.05). However, there was a significant positive correlation between the parturients' pain scores and their educational levels (r = 0.18, p = 0.018) and a significant negative correlation between pain scores and parity (r = -0.23, p = 0.009), with primigravidae having the highest perceived mean pain score compared with multiparas and grandmultiparas (7.5 +/- 2.3 vs 6.6 +/- 2.5 vs 6.3 +/- 2.1, p = 0.048). Additionally, those parturients who had their backs rubbed by a companion had a significantly higher mean perceived pain score than their counterparts whose backs were not rubbed (8.4 +/- 2.4 vs 6.8 +/- 2.9, p = 0.000). Parturients whose labours were either induced or augmented had a significantly higher perceived mean pain score than those who had spontaneous labour (8.9 +/- 2.5 vs 7.1 +/- 2.8, p = 0.001). It was concluded that parturients in Enugu, Eastern Nigeria, perceive labour as a very painful process with only a minority of them receiving any form of intra-partum analgesia. There is thus a large unmet need for pain relief among the parturients. Obstetric analgesia as is currently practiced in developed countries is long overdue in Nigeria.

Saline sonohysterosalpingographic findings in infertile Nigerian women.

This paper describes the findings in the first 100 women who underwent saline sonohysterosalpingography (SHG) at two privately owned health facilities in Enugu, South East Nigeria. This was a prospective study of the first 100 consecutive women presenting with infertility to the authors at Mbanefo Hospital and Hansa Clinics, both in Enugu, South-East geopolitical zone of Nigeria from 1 May 2005 to 20 January 2006. Saline sonohysterosalpingography was carried out in the standard way in these women. The findings were analysed using simple percentages and means +/- SD. The procedure was completed in 98 women, while in two others it was not possible to cannulate the uterine cavity. A total of 61 of the women had normal uterine musculature, 37 had interstitial fibroids and two had sonographic features of adenomyosis. Regarding the endometrial cavity, 93 women had a normal endometrium, four had a submucosal fibroid, one had intrauterine adhesions, while the endometrial cavity could not be assessed in two women who could not be cannulated. No case of submucosal polyp or uterine septa or other congenital uterine anomalies was seen. As assessed sonologically, 77 of the study subjects had bilateral patent tubes, while five had unilateral tubal patency. In one woman, there was uncertainty about tubal patency or blockage; in two women, the tubes could not be assessed because of non-cannulation of the uterine cavity and in 15 women, both tubes were blocked. A total of 74 women had normal ovaries; 15 had polycystic ovaries; five had atrophic ovaries consistent with ovarian failure and six women had ovarian cysts. In 18 women, the findings at sonosalpingography (SSG) were confirmed at laparoscopy in 11 women or laparotomy (two women) or by the fact that the patients became pregnant (five women). In 15 (83.3%) of these 18 women, the findings at SSG and laparotomy/laparoscopy or of the woman becoming pregnant were compatible. SSG is a useful screening test for assessing endometrial, tubal and ovarian factors in infertile Nigerian women, thereby obviating the need for laparoscopy and hysteroscopy in the majority of cases.

Pregnancy after heart valve replacement--case report.

There is an increased risk of thromboembolism, anticoagulant-related haemorrhage, foetal-wastage, and congestive cardiac failure in pregnant women with mechanical heart valves. Pregnancy in such patients is a high risk venture. In order to have a good outcome, the care of such patients must necessarily be multidisciplinary and in a well-equipped centre with adequate support services. One such patient who had mechanical mitral valve replacement in 1986 and was on warfarin anticoagulant presented in April 2003 with a first trimester pregnancy. She was in stable haemodynamic state and went through pregnancy without event. Delivery was by an elective caesarian section at 38 weeks gestation. The care of this patient during pregnancy, delivery, and puerperium is the basis of this report.